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This is the published version: FitzGerald,GerardJoseph,Shaban,RamonZ.,Arbon,Paul,Aitken,Peter,Considine,Julie,Clark,MicheleJ.,Finucane,Julie,McCarthy,SallyM.,Cloughessy,Liz,Holzhauser,Kerri,Patrick,JenniferR.,Fielding,ElaineL.andHurst,Cameron2010,Pandemic(H1N1)2009influenzaoutbreakinAustralia:impactonemergencydepartments,QueenslandUniversityofTechnology,Brisbane,QldAvailable from Deakin Research Online: http://hdl.handle.net/10536/DRO/DU:30030974Reproducedwiththekindpermissionofthecopyrightowner.Copyright:2010,TheAuthors

Pandemic (H1N1) 2009 Influenza Outbreak in Australia: Impact on

Emergency Departments.

Funded by

Pandemic (H1N1) 2009 Influenza Outbreak in Australia: Impact on Emergency Departments.



Investigators

FitzGerald, Gerard Joseph (1)

Shaban, Ramon Z (2, 6, 9)

Arbon, Paul (3)

Aitken, Peter (4)

Considine, Julie (5)

Clark, Michele J (1)

Finucane, Julie (6)

McCarthy, Sally M,(7)

Cloughessy, Liz (8)

Holzhauser, Kerri (6, 9)

Research Staff

Patrick, Jennifer R (1, 2)

Fielding, Elaine L (1)

Hurst, Cameron (1)

Copyright

© Copyright 2010 FitzGerald GJ, Patrick JR, Fielding EL, Shaban RZ, Arbon P, Aitken P, Considine J, Clark MJ, Finucane J, McCarthy SM, Cloughessy L, Holzhauser K. All rights reserved. Cover photograph © copyright 2010 Patrick JR.

Suggested citation

FitzGerald GJ, Patrick JR, Fielding EL, Shaban RZ, Arbon P, Aitken P, Considine J, Clark MJ, Finucane J, McCarthy SM, Cloughessy L, Holzhauser K. Pandemic (H1N1) 2009 Influenza Outbreak in Australia: Impact on Emergency Departments. (ISBN: 978-1-74107-322-5) Queensland University of Technology. 2010.

Institutions

1. Queensland University of Technology

2. Griffith University

3. Flinders University

4. James Cook University i


ii

5. Deakin University – Northern Health Clinical Partnership

6. College of Emergency Nursing Australasia

7. Australasian College for Emergency Medicine

8. Australian College of Emergency Nursing

9. Princess Alexandra Hospital


Executive summary

Objective

The aims of this study were to identify the impact of Pandemic (H1N1) 2009 Influenza on Australian Emergency Departments (EDs) and their staff, and to inform planning, preparedness, and response management arrangements for future pandemics, as well as managing infectious patients presenting to EDs in everyday practice.

Methods

This study involved three elements:

1. The first element of the study was an examination of published material including published statistics. Standard literature research methods were used to identify relevant published articles. In addition, data about ED demand was obtained from Australian Government Department of Health and Ageing (DoHA) publications, with several state health departments providing more detailed data.

2. The second element of the study was a survey of Directors of Emergency Medicine identified with the assistance of the Australasian College for Emergency Medicine (ACEM). This survey retrieved data about demand for ED services and elicited qualitative comments on the impact of the pandemic on ED management.

3. The third element of the study was a survey of ED staff. A questionnaire was emailed to members of three professional colleges—the ACEM; the Australian College of Emergency Nursing (ACEN); and the College of Emergency Nursing Australasia (CENA). The overall response rate for the survey was 18.4%, with 618 usable responses from 3355 distributed questionnaires. Topics covered by the survey included ED conditions during the (H1N1) 2009 influenza pandemic; information received about Pandemic (H1N1) 2009 Influenza; pandemic plans; the impact of the pandemic on ED staff with respect to stress; illness prevention measures; support received from others in work role; staff and others’ illness during the pandemic; other factors causing ED staff to miss work during the pandemic; and vaccination against Pandemic (H1N1) 2009 Influenza. Both qualitative and quantitative data were collected and analysed.

Results

The results obtained from Directors of Emergency Medicine quantifying the impact of the pandemic were too limited for interpretation. Data sourced from health departments and published sources demonstrated an increase in influenza-like illness (ILI) presentations of between one and a half and three times the normal level of presentations of ILIs. Directors of Emergency Medicine reported a reasonable level of preparation for the pandemic, with most reporting the use of pandemic plans that translated into relatively effective operational infection control responses. Directors reported a highly significant impact on EDs and their staff from the pandemic. Growth in demand and related ED congestion were highly significant factors causing distress within the departments. Most (64%) respondents established a ‘flu clinic’ either as part of

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the ED operations or external to it. They did not note a significantly higher rate of sick leave than usual.

Responses relating to the impact on staff were proportional to the size of the colleges. Most respondents felt strongly that Pandemic (H1N1) 2009 Influenza had a significant impact on demand in their ED, with most patients having low levels of clinical urgency. Most respondents felt that the pandemic had a negative impact on the care of other patients, and 94% revealed some increase in stress due to lack of space for patients, increased demand, and filling staff deficits. Levels of concern about themselves or their family members contracting the illness were less significant than expected. Nurses displayed significantly higher levels of stress overall, particularly in relation to skill-mix requirements, lack of supplies and equipment, and patient and patients’ family aggression. More than one-third of respondents became ill with an ILI. Whilst respondents themselves reported taking low levels of sick leave, respondents cited difficulties with replacing absent staff. Ranked from highest to lowest, respondents gained useful support from ED colleagues, ED administration, their hospital occupational health department, hospital administration, professional colleges, state health department, and their unions. Respondents were generally positive about the information they received overall; however, the volume of information was considered excessive and sometimes inconsistent. The media was criticised as scaremongering and sensationalist and as being the cause of many unnecessary presentations to EDs. Of concern to the investigators was that a large proportion (43%) of respondents did not know whether a pandemic plan existed for their department or hospital. A small number of staff reported being redeployed from their usual workplace for personal risk factors or operational reasons. As at the time of survey (29 October –18 December 2009), 26% of ED staff reported being vaccinated against Pandemic (H1N1) 2009 Influenza. Of those not vaccinated, half indicated they would ‘definitely’ or ‘probably’ not get vaccinated, with the main reasons being the vaccine was ‘rushed into production’, ‘not properly tested’, ‘came out too late’, or not needed due to prior infection or exposure, or due to the mildness of the disease.

Conclusion

Pandemic (H1N1) 2009 Influenza had a significant impact on Australian Emergency Departments. The pandemic exposed problems in existing plans, particularly a lack of guidelines, general information overload, and confusion due to the lack of a single authoritative information source. Of concern was the high proportion of respondents who did not know if their hospital or department had a pandemic plan. Nationally, the pandemic communication strategy needs a detailed review, with more engagement with media networks to encourage responsible and consistent reporting. Also of concern was the low level of immunisation, and the low level of intention to accept vaccination. This is a problem seen in many previous studies relating to seasonal influenza and health care workers. The design of EDs needs to be addressed to better manage infectious patients. Significant workforce issues were confronted in this pandemic, including maintaining appropriate staffing levels; staff exposure to illness; access to, and appropriate use of, personal protective equipment (PPE); and the difficulties associated with working in PPE for prolonged periods. An administrative issue of note was the reporting requirement, which created considerable additional stress for staff within EDs. Peer and local support strategies helped ensure staff felt their needs were provided for, creating resilience, dependability, and stability in the ED workforce. Policies regarding the establishment of flu clinics need to be reviewed. The ability to create surge capacity within EDs by considering staffing, equipment, physical space, and stores is of primary importance for future pandemics.

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Acknowledgements1. Research staff: Research Fellow Elaine Fielding, Research Assistant Jennifer Patrick,

Biostatistician Cameron Hurst.

2. For access to data, Queensland’s Chief Health Officer Jeanette Young, the staff of the Victorian Health Information Reporting System, the staff of the Western Australian Communicable Disease Control Directorate, and the staff of the South Australian Communicable Disease Control Branch.

3. Queensland University of Technology Human Research Ethics Committee for review and permission to proceed.

4. National Health and Medical Research Council for funding.

5. Survey participants for giving us their time and the benefit of their experiences.

6. Peter Aitken is partially supported by a Noel Stevenson Fellowship through the Queensland Emergency Medicine Research Foundation.

NH&MRC grantApplication title: Emergency Department impact and patient profile of H1N1 Influenza 09 outbreak in Australia: A national survey.

Application number: 614290

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Acronyms and abbreviations

Acronym/abbreviation DefinitionACEM Australasian College for Emergency MedicineACEN Australian College of Emergency NursingACOEM American College of Occupational and Environmental MedicineACT Australian Capital TerritoryADON Assistant Director of NursingAHMPPI Australian Health Management Plan for Pandemic Influenza

2008ANZICS Australian and New Zealand Intensive Care SocietyAPIC Association for Professionals in Infection Control and Epidemi-

ology Inc.BiPAP Bilevel Positive Airway PressureCBR Chemical, biological and radiologicalCDC Centers for Disease Control and PreventionCENA College of Emergency Nursing AustralasiaCF Clinical FacilitatorCN Clinical NurseCNE Clinical Nurse EducatorCNS Clinical Nurse SpecialistCPAP Continuous Positive Airway PressureDoHA Department of Health and AgeingDON Director of NursingECMO Extra Corporeal Membrane OxygenationED Emergency DepartmentFACEM Fellow of the Australian College for Emergency MedicineGP General PractitionerH HaemagglutininICU Intensive Care UnitIDSA Infectious Diseases Society of AmericaILI Influenza-like IllnessIQR InterQuartileRankLMO Local Medical OfficerMeSH Medical Subject HeadingsMPERT Mobile Paediatric Emergency Response Team N NeuraminidaseND Nursing DirectorNH&MRC National Health and Medical Research CouncilNP Nurse PractitionerNSW New South WalesNSW Health New South Wales HealthNT Northern Territory

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Acronym/abbreviation DefinitionNUM Nursing Unit ManagerPAHO Pan American Health OrganizationPPE Personal protective equipmentQ Health Queensland HealthQld QueenslandRBWH Royal Brisbane Women’s HospitalRCH Royal Children’s HospitalRN Registered NurseSA South AustraliaSARS Severe Acute Respiratory SyndromeSD Standard DeviationSESIAHS South Eastern Sydney and Illawarra Area Health ServiceSHEA Society for Healthcare Epidemiology of AmericaSMO Senior Medical OfficerTas TasmaniaTGA Therapeutic Goods AdministrationUK United KingdomUSA United States of AmericaVic VictoriaVIDRL Victorian Infectious Diseases Reference LaboratoryVIP Very Important PersonWA Western AustraliaWHO World Health Organization

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Contents

PANDEMIC (H1N1) 2009 INFLUENZA OUTBREAK IN AUSTRALIA: IMPACT ON EMERGENCY DEPARTMENTS. ................................................................I

Investigators .......................................................................................................................................iResearch Staff ....................................................................................................................................iCopyright ...........................................................................................................................................iSuggested citation .............................................................................................................................iInstitutions .........................................................................................................................................iEXECUTIVE SUMMARY .....................................................................................................III

Objective ......................................................................................................................................... iiiMethods .......................................................................................................................................... iiiResults ............................................................................................................................................. iiiConclusion .......................................................................................................................................ivACKNOWLEDGEMENTS..................................................................................................... V

NH&MRC GRANT ................................................................................................................. V

ACRONYMS AND ABBREVIATIONS .............................................................................. VII

1. INTRODUCTION ............................................................................................................... 1

2. BACKGROUND .................................................................................................................. 1

Influenza pandemics ........................................................................................................................1The (H1N1) 2009 influenza pandemic ............................................................................................3History and overview ........................................................................................................................................3Australia’s response ............................................................................................................................................4Clinical profile and impact on Emergency Departments ..........................................................................7The planning context for pandemics ..............................................................................................................8The operational context of Emergency Departments .............................................................................. 10The role of EDs in disaster and pandemic response ................................................................................. 11Impact of Pandemic (H1N1) 2009 Influenza on Emergency Departments ...............................13Staffing issues ................................................................................................................................................... 15Immunisation ................................................................................................................................................... 17Summary ........................................................................................................................................................... 173. RESEARCH QUESTION, AIM, OBJECTIVES, AND METHODS ................................ 17

Project governance .........................................................................................................................18Project overview .............................................................................................................................18Phase 1—Initiation (months 1 and 2)........................................................................................................ 18Phase 2—Data collection (months 3 and 4) ............................................................................................. 18Phase 3—Data analysis and reporting (months 5 and 6) ....................................................................... 19Ethics review ...................................................................................................................................194. FINDINGS ......................................................................................................................... 20

Overview of state data ....................................................................................................................20Introduction ..................................................................................................................................................... 20

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New South Wales ............................................................................................................................................ 20Northern Territory ......................................................................................................................................... 21Queensland ...................................................................................................................................................... 21South Australia ................................................................................................................................................ 21Tasmania ........................................................................................................................................................... 23Victoria .............................................................................................................................................................. 23Western Australia ............................................................................................................................................ 24Special topics ................................................................................................................................................... 24General staff survey ........................................................................................................................27Quantitative data results ................................................................................................................................ 27Response rates ................................................................................................................................................. 27Demographics of respondents...................................................................................................................... 27Emergency Department conditions during (H1N1) 2009 influenza pandemic ................................ 28Information received concerning Pandemic (H1N1) 2009 Influenza .................................................. 29Pandemic plans ................................................................................................................................................ 29Impact on Emergency Department staff .................................................................................................... 29Stress .................................................................................................................................................................. 29Preventive measures ....................................................................................................................................... 30Support received from others in work role ................................................................................................ 30Own and other’s illness during pandemic .................................................................................................. 30Other factors causing Emergency Department staff to miss work during pandemic ........................ 31Redeployment during pandemic ................................................................................................................. 31Vaccination against Pandemic (H1N1) 2009 Influenza ............................................................................ 31Staff opinions about Pandemic (H1N1) 2009 Influenza topics ............................................................. 32Qualitative data analysis methodology ....................................................................................................... 32Qualitative data results ................................................................................................................................... 36Information ...................................................................................................................................................... 36Pandemic plans ................................................................................................................................................ 37Staff stress ......................................................................................................................................................... 39The five most difficult aspects of dealing with the (H1N1) 2009 influenza pandemic ..................... 40Other preventative measures used to protect ED staff ............................................................................ 40Staff support ..................................................................................................................................................... 41Help from employers that respondents did not receive during illness................................................. 42Other reasons for missing work ................................................................................................................... 43Feelings or concerns about the Pandemic (H1N1) 2009 Influenza vaccine and getting vaccinated 43Was this a health emergency—why or why not? ...................................................................................... 43Should Emergency Departments take responsibility for managing pandemic influenza? ............... 44Suggestions for improvement ....................................................................................................................... 45Other comments ............................................................................................................................................. 46Directors’ survey ............................................................................................................................47Response rate ................................................................................................................................................... 47Demographics of respondents’ hospitals and Emergency Departments ............................................. 47

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Infectious disease wards and flu clinics ...................................................................................................... 48Pandemic and disaster plans ......................................................................................................................... 48Departmental responses to Pandemic (H1N1) 2009 Influenza ............................................................. 48Effect of pandemic on Emergency Departments ...................................................................................... 495. DISCUSSION .................................................................................................................... 50

Introduction ...................................................................................................................................50The operational context .................................................................................................................50The planning context ......................................................................................................................52Impact on Emergency Departments .............................................................................................53Impact on Emergency Department staff ......................................................................................55Conclusion and lessons..................................................................................................................56Limitations ......................................................................................................................................58REFERENCES ....................................................................................................................... 59

APPENDICES ...................................................................................................................... A-1

A: General staff survey quantitative data tables .........................................................................A-1Table A-1. Demographic characteristics of respondents and their hospitals .................................... A-1Table A-2. Role and qualifications of doctor and nurse respondents ................................................. A-2Table A-3. Preparedness of Emergency Department for the Pandemic (H1N1) Outbreak ........... A-3Table A-4. How much extra demand from H1N1 pandemic ................................................................. A-3Table A-5. Mix of influenza cases in terms of severity of illness .......................................................... A-3Table A-6. Impact of H1N1 pandemic on the care of other ED patients ............................................ A-5Table A-7. Characteristics of information received about the H1N1 pandemic ............................... A-5Table A-9. Effect of H1N1 pandemic on ED staff stress level ................................................................ A-7Table A-10. Deployment and ease of use of preventive measures to protect staff from

H1N1 (2009) infection ......................................................................................................................... A-13Table A-11. How supportive were different groups of ED staff ’s needs during the

H1N1 pandemic ...................................................................................................................................... A-16Table A-12. ED staff illness during the H1N1 pandemic ...................................................................... A-18Table A-13. ED staff caring for others (outside of work) with ILI during H1N1 pandemic ......... A-19Table A-14. Factorsa causing ED staff to miss work during H1N1 pandemic .................................. A-20Table A-15. ED staff redeployment during H1N1 pandemic .............................................................. A-21Table A-16. Action and intention with vaccination against H1N1 (2009) ...................................... A-21Table A-17. Staff opinions about H1N1 topics ....................................................................................... A-22B: Emergency department directors’ survey tables ...................................................................B-1Table B-1. Demographics of survey respondents’ hospitals and EDs ................................................ B-1Table B-2. Infectious disease wards and flu clinics ................................................................................. B-2Table B-3. Pandemic and disaster plans ................................................................................................... B-3Table B-4. Clinical protocols for dealing with suspected H1N1 presentations? ............................... B-4Table B-5. Administrative measures employed during the (H1N1) 2009 Influenza Pandemic .... B-4Table B-6. Measures used to prevent the spread of Pandemic (H1N1) 2009 Influenza .................. B-5Table B-7. Level of difficulty experienced in ED with following issues during the

(H1N1) 2009 Influenza Pandemic ....................................................................................................... B-6

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Table B-8. Amount of sick or family leave taken by ED staff during the (H1N1) 2009 Influenza Pandemic ................................................................................................................................ B-8

Table B-9. Emergency department directors’ survey tables ................................................................. B-9Table B-9. Emergency department directors’ survey tables (continued) ........................................ B-10Table B-10. Comparison of after-hours ILI presentations 2009 versus previous years ................ B-13C: Qualitative data terms for Leximancer ................................................................................. C-1D: Ethics approval ....................................................................................................................... D-1

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1

1. IntroductionEmergency Departments (EDs) and ambulance services are at the forefront of Australia’s health disaster response providing immediate patient care, system wide coordination, and retrieval and transfer of patients. The recent outbreak of Pandemic (H1N1) 2009 Influenza demonstrated the diversity of roles EDs play in disease containment and management. Public awareness of Pandemic (H1N1) 2009 Influenza and concern about the potential severity of the disease led to a large number of patients presenting to both EDs and primary health services, including General Practitioners (GPs) and ambulance services. However, the extent of the impact of Pandemic (H1N1) 2009 Influenza on EDs and their staff has not previously been documented in detail.

The Pandemic (H1N1) 2009 Influenza outbreak had a significant impact on EDs with large numbers of patients presenting with influenza-like illness (ILI), which caused considerable demands on ED staff and further impeded the management and flow of ED patients1, 2. This occurred at a time when EDs in Australia are confronting continual problems of overcrowding associated with ‘access block’ and growing service demands. EDs had to respond to the additional demand caused by the Pandemic (H1N1) 2009 Influenza outbreak and to implement specific precautions to safely manage these patients, whilst also protecting staff members and non-affected patients and visitors from potential cross-contamination.

The response by EDs to the Pandemic (H1N1) 2009 Influenza outbreak occurred during a period of evolving knowledge about the disease. Initial reports from Mexico raised serious concerns regarding the severity of the disease and the mortality rate. Although the severity was subsequently shown to be of less concern, the initial response was, and necessarily had to be, based on the information available at the time.

The aim of this study was to identify the impact of Pandemic (H1N1) 2009 Influenza in Australia on ED operations and staff; to inform future planning, preparedness, and response management arrangements for pandemics; and to inform the management of infectious patients presenting to EDs in every day practice.

2. Background

Influenza pandemics

Influenza viruses are myxoviruses, with three main genera—Influenza A, B, and C—all of which are capable of causing infection in humans3, 4. Influenza A is responsible for epidemics, and occasional pandemics in humans5. Influenza B does not cross the species barrier, but can cause epidemics4. Influenza C has, to date, only caused mild illness, and does not cause epidemics4, 6.

The outer coat of the influenza virus has two antigens: haemagglutinin (H), which anchors the virus to cells it invades; and neuraminidase (N), which helps the virus both enter and exit individual host cells. Influenza A subtypes are named according to which antigen they possess. Humans manufacture antibodies to these antigens during the immune response4. Only Influenza A subtypes H1, H2, and H3 have been readily transmitted between humans. However, these


2

antigens are altered over time by a process of drift (repeated minor mutations), or shift when two different influenza viruses invade a host simultaneously and recombine to produce marked changes in surface antigens6. Shift commonly occurs in Influenza A, but not in Influenza B or C. Haemagglutinin is used in the manufacture vaccines. The influenza virus is able to change this outer surface antigen frequently, which means annual changes are needed in the manufacture of influenza vaccines3, 4, 6.

An ‘epidemic’ is defined as the sudden increase in the incidence of a disease within a defined locality4. A ‘pandemic’ is defined as the spread of a disease outside a community and across the world4. Pandemics can persist for months, years, or decades, and pandemic influenza includes rapid transmission with the disease occurring outside usual seasonal patterns, with high attack rates across all age groups and high mortality rates in young, healthy adults6. Epidemics and pandemics of influenza occur when a new virus emerges, or an existing virus mutates sufficiently for little or no immunity to exist3, 4. Influenza pandemics have occurred regularly over the course of history. They arise when a virus develops to which the population has little or no immunity, and efficient human-to-human transmission occurs.

The predominant virus type causing epidemics has evolved over time. The so-called Spanish Flu of 1918–19 was caused by an Influenza A virus of subtype H1N1. It killed more people than were killed in World War I7. Recent reconstruction of this virus shows marked similarity to swine influenza viruses of the H1N1 type isolated in pigs since the 1930s. The Spanish Flu killed an estimated 40–50 million people across the world when the world’s population was 1.7 billion. Subsequent influenza pandemics occurred in 1957 (‘Asian Flu’ caused by H2N2); in 1968 (‘Hong Kong Flu’ caused by H3N2); in late 1976 (the re-emergence of H1N1, which caused an outbreak at a North American military base); and in 1977 the ‘Russian Flu’8, 9. The 1976 outbreak was feared to be the start of a pandemic of similar proportions to that of 1918–19, so a vaccine was rapidly rolled out and US citizens were compulsorily immunised. This immunisation campaign was halted when a higher than normal rate of Guillain–Barré Syndrome was detected amongst those immunised and a pandemic failed to eventuate10.

Previous major pandemics occurred before the development of many modern health care innovations that are now considered as standard care. During the 1918–19 Spanish Flu pandemic, most people died from bacterial infections. This was before the development of antibiotics11. In Australia, the 1968 pandemic occurred when intensive care units were only in a developmental stage8.

Since 1918–19, there have been many changes in society that have altered the potential risk profile of the community. Populations in large cities are bigger and populations are also relatively far more mobile. High-speed international travel means that pandemics spread around the world very quickly4. Travel during the incubation period of viruses devalues any benefits of border controls. However, there are also positive societal changes that may mitigate some of these risks. Populations are now healthier with fewer chronic infectious diseases (particularly tuberculosis); people in the developed world live mostly in relatively isolated, separate quarters and benefit from better environmental standards and have more access to sophisticated medical care than in 1918–194.

The impact of infectious diseases on the burden of disease in developed countries has reduced considerably over the last century, due to the development of antibiotics and the introduction of infection control practices. However, in developing countries, illnesses such as HIV/AIDS,


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tuberculosis and malaria, together with vaccine preventable childhood diseases5 remain significant contributors to both mortality and disease burden4. The outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003, followed by Avian Influenza (H5N1), raised awareness of the potential impact of novel viruses on human health and led to enhanced preparedness for pandemic management. Avian Influenza is spread by migratory birds, is highly infectious for chickens, and lethal when contracted by humans with a mortality rate of 60%4. Concern that H5N1 may mutate into a human-to-human transmissible form has sensitised the world to potential impact of a major pandemic.

The (H1N1) 2009 influenza pandemic

History and overview

The emergence of a Swine Influenza virus that causes human disease resulted in international alarm. Though infection is novel, this virus is not new and is thought to have been undetected within herds of swine for quite some time prior to human infection, evidenced by the lack of similarity between the Swine Influenza and its nearest relatives9, 12.

In March and early April 2009, a larger than usual number of cases of ILI were detected in Mexico3, 13. This was first reported to the Pan American Health Organization (PAHO) on 12 April, and enhanced surveillance began in Mexico on 17 April. On 23 April it was shown that the virus involved was the same as that found in two children in Texas on 15 April, and in two more children in California on 17 April. On 23 April, the Public Health Agency in Canada confirmed similar cases13. A lack of contact with pigs in all the reported cases led to the conclusion that transmission of the virus was human to human9, 13.

Investigations revealed the virus was an Avian Influenza virus, which had not previously been known to cause human disease. The virus is known by various names—Swine Flu, swine-origin influenza A (H1N1) virus (S-OIV) infection; Pandemic (H1N1) 2009; and Novel Influenza A (H1N1) Virus. Throughout this paper it is referred to as Pandemic (H1N1) 2009 Influenza. Pandemic (H1N1) 2009 Influenza is a quadruple reassortment virus, with North American and Eurasian swine strains combining with one avian and one human strain12.

On 25 April 2009, the World Health Organization (WHO) determined that member states and partners should increase their surveillance programs and prepare for an epidemic14. Australia activated its pandemic plan, The Australian Health Management Plan for Pandemic Influenza 2008 (AHMPPI 2008)19, in line with this recommendation15. Two days later, the WHO determined that, given the extent of the spread of the disease, containment would not be possible. Countries were advised not to institute border control measures, but to implement plans to lessen the impact of the outbreak. On 27 April, the WHO advised that given the evidence of sustained human-to-human infection, countries should aim for early detection, management, and implementation of appropriate infection control procedures14, and to upgrade assessment of the pandemic from Level 4 to Level 5 (see Figure 1). Australia’s first Pandemic (H1N1) 2009 Influenza case was reported on 9 May16. Pandemic (H1N1) 2009 Influenza appeared to be both highly contagious and virulent. By 29 May, Mexico reported 4910 confirmed cases and 85 deaths17.


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Figure 1 World Health Organization pandemic phases18

Australia’s response

The AHMPPI 200819 was activated on 25 April 2009 when the WHO advised increased surveillance for unusual outbreaks of ILI and pneumonia and recommended appropriate case management strategies and strengthened infection control measures in health14. Before the virus arrived in Australia, there were predictions of a high mortality rate related to the virus15. The first case of Pandemic (H1N1) 2009 Influenza in Australia was in a person who arrived on a flight from Los Angeles on 7 May 2009. The person had been ill in the USA from 27 April, and approached staff at Brisbane Airport to inform them on arrival. The swab returned a weak positive result on 9 May and she was deemed non-infectious20. On 18 May, the first cases were reported in Victoria in three brothers who had recently returned from the USA. Surveillance systems showed the virus spread quickly and it rapidly became the predominant strain over seasonal influenza16, 21. These events are summarised in Table 1.

Table 1 Australian Pandemic (H1N1) 2009 Influenza timeline

28 April Pandemic (H1N1) 2009 Influenza designated a quarantinable disease.Border surveillance strengthened.The Australian Pandemic Phase upgraded from the ALERT Phase to DELAY Phase.

30 April Full border measures implemented, with thermal scanners in eight Australian international airports following WHO upgrade of Influenza Pandemic Alert Phase 4 to Influenza Pandemic Alert Phase 5.National freecall Pandemic (H1N1) 2009 hotline and health emergency website established.

9 May Australia has first confirmed case of Pandemic (H1N1) 2009 Influenza with person in Queensland testing weak positive. The person arrived in Brisbane on 7 May from Los Angeles.As a precaution, health authorities contact traced people on the same flight.

21 May Four more Australians tested positive to Pandemic (H1N1) 2009—three in Victoria and one in NSW.

22 May South Australia had first confirmed case of Pandemic (H1N1) 2009.Pandemic alert level escalated to CONTAIN.

PHASES 1-3 POST PANDEMIC

PHASE 4 POST PEAK

PHASES 5-6 / PANDEMIC

TIME

PREDOMINANTLY ANIMAL

INFECTIONSFEW HUMAN INFECTIONS

SUSTAINED HUMAN TO

HUMAN TRANSMISSION

WIDESPREAD HUMAN

INFECTION

POSSIBILITY OF RECURRENT

EVENTS

DISEASE ACTIVITY AT SEASONAL

LEVELS

PANDEMIC INFLUENZA PHASES


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23 May NSW Health advised by Australian Quarantine and Inspection Service that cruise ship, Dawn Princess, travelling from Hawaii to Sydney had passengers on board with influenza like illness. NSW Health with DoHA, requested delayed disembarkation of passengers and crew for assessment of symptoms by Public Health Officials. Passengers and crew then disembarked the ship and were instructed to stay in isolation until tests results known.

24 May Results for passengers on board the Dawn Princess cruise ship negative for Pandemic (H1N1) 2009.

25 May Western Australia had first confirmed case.27 May As a precaution for its visit to the Whitsunday Islands, the Pacific Dawn

cruise ship sailed to Willis Island to allow extra time at sea to test those who developed symptoms and to monitor for development of further cases. Three people on the ship tested positive for influenza. Swabs taken for Pandemic (H1N1) 2009. All passengers from previous cruise had disembarked in Sydney, with crew given Oseltamivir and any showing ILI symptoms sent off the ship.

28 May The Chief Medical Officer approved first release of antivirals from the National Medical Stockpile.Queensland Health confirmed three crew members on the Pacific Dawn tested positive for Pandemic (H1N1) 2009.

29 May Pacific Dawn diverted back to Brisbane.30 May Queensland Health prepared for Pacific Dawn arrival in Brisbane. Other

passengers isolated after showing ILI symptoms.31 May The Northern Territory announced first case of Pandemic (H1N1) 2009. All

Australian states and territories now had at least one confirmed case.1 June NSW Health advised Pacific Dawn cruise ship passengers all returned

negative results for Pandemic (H1N1) 2009.3 June Containment measures in place in Sydney for arrival of Dawn Princess

cruise ship turned away from Noumea after passengers with ILI symptoms.

11 June WHO Director-General, Dr Margaret Chan, escalated level of influenza pandemic alert from Phase 5 to Phase 6, recognising continued spread of Pandemic (H1N1) 2009 Influenza around the world, with sustained human-to-human community level transmission. Acknowledged causing mainly moderate disease.

17 June New pandemic phase PROTECT created to guide ongoing Australian response to Pandemic (H1N1) 2009 Influenza. Recognised Pandemic (H1N1) 2009 not as severe as envisaged when AHMPPI written in 2008. PROTECT to sit alongside CONTAIN and SUSTAIN phases with greater focus on treatment and care for people experiencing severe disease.Jurisdictions made arrangements to move to this level 26 June.

18 September Therapeutic Goods Administration (TGA) announced registration of CSL Pandemic (H1N1) 2009 Influenza vaccine.

30 September All States and Territories offered free vaccine to adults and children 10 years and over.

Note: All dates and information in Table 1 derived from the Australian Government Department of Health and Ageing’s (DoHA) Pandemic (H1N1) 2009 Influenza news archive22.


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Australia’s Pandemic (H1N1) 2009 Influenza phases are summarised in Table 2.

Table 2 Australian Pandemic (H1N1) 2009 Influenza phases23

As at 9 April 2010, there were 37,693 confirmed cases of Pandemic (H1N1) 2009 Influenza in Australia, with 191 Pandemic (H1N1) 2009 Influenza related deaths24. However, the number of reported cases vastly under-represents the total number of cases, because testing was deliberately phased out in the SUSTAIN phase of the disease. Pandemic (H1N1) 2009 Influenza was the dominant influenza of the 2009 winter season. Whilst the peak incidence of Pandemic (H1N1) 2009 Influenza in Australia was in September 2009, sporadic cases continued throughout the summer. The disease has continued throughout the northern hemisphere during the winter.

The laboratory-confirmed cases are a small proportion of the health burden that occurs during any outbreak. The major burden of disease during pandemics is carried by those with relatively

Australian phase Description

ALERT

DELAY

CONTAIN

SUSTAIN PROTECT

CONTROL

RECOVER

A novel virus with pandemic potential causes severe disease in humans who have had contact with infected animals. There is no effective transmission between humans. Novel virus has not arrived in Australia.

Effective transmission of novel virus detected overseas in either:• small cluster of cases in one country overseas• large clusters of cases in only one or two countries overseas• large clusters of cases in more than two countries overseas.Novel virus not detected in Australia.

Pandemic virus has arrived in Australia causing a small number of cases or a small number of clusters.

Pandemic virus is established in Australia and spreading in the community.

A pandemic virus that is mild in most, but severe in some, and moderate overall is established in Australia.

Customised pandemic vaccine widely available and is beginning to bring the pandemic under control.

Pandemic controlled in Australia, but further waves may occur if the virus drifts or is re-imported into Australia.


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mild illness who do not seek or require medical care. In determining the whole clinical impact of Pandemic (H1N1) 2009 Influenza, there are a number of categories to assess:

1. ‘proven’ cases including:

a. those with mild symptoms managed at home

b. those needing hospital admission

c. those with Intensive Care Unit (ICU) admission

d. those dying

2. patients with the disease who are not tested

3. patients with different, but similar diseases

4. patients who are concerned, but not unwell

5. family, friends, and contacts who require prophylaxis.

Many patients with ILI who are concerned they have Pandemic (H1N1) 2009 Influenza will present for assessment. In many of these patients, Pandemic (H1N1) 2009 Influenza will be a differential diagnosis and the inherent delay in obtaining confirmed diagnosis requires provisional prophylactic intervention for the patient and their immediate contacts. At times, the extent of these contacts may be extreme—for example, all other passengers on an airliner or all children in a school. Therefore, the major burden of disease during a pandemic such as that experienced in 2009 is largely experienced by those who do not have a serious disease.

Clinical profile and impact on Emergency Departments

Early in the Pandemic (H1N1) 2009 Influenza outbreak, there was concern that a mild outbreak could lead to accusations of scaremongering and cause reduced future compliance with public health emergency initiatives25. As the pandemic progressed, there was a view that a great deal of unnecessary alarm was created by the media26. Even as early as July 2009, a small study in Sydney found a low level of community anxiety about Pandemic (H1N1) 2009 Influenza. However, the authors of this study felt that the media played a significant part in the community’s acceptance and positive attitude towards quarantine as an infection control measure27.

At the commencement of this outbreak, in the first instance health departments directed patients with ILI to ED28, with television and newspapers reporting ensuing chaos29–36. In the USA, large influxes of patients with influenza symptoms were reported to be attending EDs, and all patients were tested for the virus, including those without symptoms. This increased demand on EDs was related to the extent of the disease in the community, the degree of testing for the disease within the community, and the interest the local media showed in the outbreak37.

Over time and with the accumulation of data, it became evident that Pandemic (H1N1) 2009 Influenza had a high infection rate, but mainly caused mild to moderate disease, with the usual features of influenza—fever ≥38.0oC, sore throat, cough, runny nose, chills, head and body aches,


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and fatigue. Pandemic (H1N1) 2009 Influenza differed from usual seasonal influenza because approximately half of the cases had associated nausea, abdominal pain, and diarrhoea38, and because it affected predominantly younger age groups21, whereas the major impact of seasonal influenza is on the elderly4. It is thought that older people may have cross-reactive antibodies from exposure to a similar virus in the past39. However, when people over the age of 65 are infected with Pandemic (H1N1) 2009 Influenza, they have the highest mortality rate of any age group40. The mortality rate from Pandemic (H1N1) 2009 Influenza is lower than that from seasonal influenza, though the people who died were typically younger than those who die from seasonal influenza41. In severe cases, Pandemic (H1N1) 2009 Influenza causes extremely severe lung disease resulting in higher rates of ICU admissions than seasonal influenza, and a need for advanced ventilation and oxygenation techniques such as Extra Corporeal Membrane Oxygenation (ECMO). The most severe respiratory failure occurs in patients aged less than 50 years, with many requiring prolonged ventilation42–47.

Those at higher risk of severe disease as a result of Pandemic (H1N1) 2009 Influenza included pregnant women; children aged six months to 10 years on long-term aspirin therapy; adults who were moderately to morbidly obese; people with pre-existing respiratory problems, especially asthma; those with pre-existing cardiovascular disease; immunosupressed people; people with chronic illnesses such as diabetes and metabolic, liver, and neural diseases; people with haemoglobinopathies; homeless people; and people from Indigenous backgrounds38, 48, 49. The higher vulnerability of Indigenous Australians highlighted the need for culturally sensitive and specific information and health care to be delivered by trusted individuals to this sector of the community50. Whilst an early report suggested that vaccination with previous seasonal vaccines offered no protection against the Pandemic (H1N1) 2009 Influenza virus in any age group16, a later report from Mexico suggested that some protection was conferred by the 2008–09 trivalent inactivated vaccine, especially against severe forms of Pandemic (H1N1) 2009 Influenza51. Another recent report, compiled from four studies in Canada, concluded that those who received the seasonal 2008–09 trivalent vaccine were more likely to contract Pandemic (H1N1) 2009 Influenza than those who had not been vaccinated52. There is obviously more work to be done in this area.

The planning context for pandemics

Planning for pandemics requires building large-scale surge capacity into the health care system. Unlike other disasters, pandemics last for up to 7–10 months, and can cause significant health, economic, and social impacts for extended periods53.

In 2004, the WHO developed a checklist for developing pandemic plans. The essential features of the checklist included preparation for an emergency, surveillance, investigation of cases and treatment, prevention of community spread, maintenance of essential services, research and evaluation, and the implementation, testing and revision of the plan5. In Australia, the DoHA devised the AHMPPI, which was tested using a simulation exercise in 2006, called ‘Exercise Cumpston 06’. Key recommendations that emerged from Exercise Cumpston 06 included streamlining decision-making processes, increased flexibility to respond according to the severity of the pandemic and the available resources; improved communication systems including sharing information between jurisdictions; public health education campaigns ahead of time; a national surveillance framework; clarification of quarantine, border control, and emergency legislation; and integration of primary care providers in pandemic planning54. In 2008, ‘Exercise Sustain 08’ was held to further review the AHMPPI for government preparedness at a national level to respond to and recover from pandemic influenza. Exercise Sustain 08 underscored the impact


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a pandemic would have, both during the outbreak and in the recovery phase, on all facets of the community. It identified differences between the response required during a pandemic, and that required for other disaster situations such as floods, fires, and mass casualty situations, which are usually geographically defined and of shorter duration53. Exercise Sustain 08 also stressed that it is impossible to plan for all eventualities, given that it is impossible to predict the characteristics of a new virus. Community empowerment on a local level emerged as an issue from Exercise Sustain 08, and it was recommended neighbourhood leaders and existing community groups should be identified and involved in pandemic planning. The notion of clearly defined social distancing also emerged as an important prevention strategy. The impact of social distancing on the health care workforce was also examined. The need for defined criteria for measures such as school closures was identified. A way of developing a productive relationship with the media was also identified, with an emphasis on timeliness, transparency, and honesty to earn the trust of the community. The importance of the credibility of the person delivering the messages was also identified, with health professionals rather than politicians being considered more likely to instil confidence in the community37, 53. The findings of a recent Australian study echoed the importance of credibility, and also emphasised the need for local sources of information55.

Worldwide, health care systems have few surplus resources. However, the ability to expand capacity to meet health needs during a crisis is imperative. This concept, known as ‘surge capacity’ has been defined as, ‘the ability to manage a sudden, unexpected increase in patient volume (i.e. numbers of patients) that would otherwise severely challenge or exceed the current capacity of the health care system’56. Surge capacity can be created in a number of ways. It is recognised that during a pandemic, non-essential and non-emergency functions within hospitals may need to be suspended for the duration of the crisis. This may include cancelling elective surgery and admissions, earlier than usual discharge of patients, removal of ambulatory care from hospitals, and reallocation of physical space and roles56. Staff and volunteers need specialised training in advance; supplies such as ventilators, drugs, and PPE need to be stockpiled; and there must be increased capacity for cleaning and security and crowd management. Morgue facilities must also be able to expand, and laboratory capacity may need to expand exponentially. Screening, testing, and prophylaxis must be available for health care workers to protect them and enable them to keep working. There is also increased need for non-medical staff to fulfil roles in administration, communication, transportation, and security and crowd control. However, surge capacity applies across the entire community, with health, government, and community groups required to act in an integrated and cooperative manner. When individual hospitals reach the limit of their capacity to cope, they must be able move patients or services to other hospitals or centres25, 57. Illness amongst health care workers also increases pressure within the system. Resultant loss of workforce numbers needs to be planned for and covered by casual staff, retired staff, and volunteers56.

All Australian states have pandemic plans designed to complement or augment the AHMPPI58–66. These plans agree that flu clinics should be established to minimise the impact of a pandemic on EDs. Flu clinics allow EDs to continue to meet emergency care needs of communities. Pandemic plans also recommend separating influenza patients from other patients at triage, with the designation of ‘flu hospitals’ to keep those infected separated from patients who do not have the virus. Other recommendations include priority vaccination for at-risk staff, pre- and post-exposure prophylaxis for staff who come into contact with suspected and confirmed cases, and the use of PPE with access to pandemic stockpiles as required. Hospital staff are expected to self-isolate if exposed or ill58–66.


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The attack on the World Trade Center in the USA on 11 September 2001, the experience of SARS in 2002–03, various threats of biological warfare, and the Asian Tsunami on 26 December 2004 have heightened worldwide awareness of the need for medical communities to develop plans to create surge capacity within hospitals and communities to better cope in a pandemic or mass casualty situation.

The operational context of Emergency Departments

EDs and ambulance services form the core of Australia’s emergency medical system. These services not only manage the daily workload associated with individual health emergencies, but also form the core of the immediate health response to major incidents and disasters. Pandemics pose a particular challenge to Australia’s health system as they can result in a widespread and prolonged increase in demand for health care, which may challenge the capacity of the health system.

There are longstanding crowding problems in Australian EDs. Since the 1990s, the greatest contributing factor to overcrowding in EDs is ‘access block’67. Access block occurs when patients requiring an inpatient bed are unable to be transferred to inpatient areas, and remain in the ED for prolonged periods. Access block is an indication of systemic problems within the hospital system rather than inefficiencies within the ED. Decreases in bed requirements due to reduced lengths of hospital stays have been outstripped by the increase in patient numbers. Many patients have increasingly complex health problems. An ageing population, and an increased incidence of chronic illness, combined with advances in diagnostic and therapeutic technology have caused an increase in the demand for inpatient beds. However, bed numbers per capita decreased by 18% between 1995–96 and 2005–06 after larger per capita reductions in the previous 20 years67. In 2007–08, Australia had 2.5 public hospital beds per 1000 weighted population, and over 7.1 million visits to EDs68. Figure 3 shows the stability in hospital bed numbers compared with the increase in ED presentations69.

Figure 2 Australian trends in ED utilisation and bed availability (2002–07)69

An ageing population with higher expectations, and overstretched community health care options, compound this problem70.

01998-99 2002-03 2003-04 2004-05 2005-06 2006-07

1

2

3

4

5

6

7

8

3.46

2.65

ED presentations per year (in millions)

Beds available per 1000 population

3.804.10

4.334.76

6.74

2.43 2.47 2.60 2.60 2.60

KEY


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The use of EDs as GP services contributes to overcrowding of ED waiting rooms. In normal times, patients who use EDs as GP services have a relatively low level of impact on how the ED functions because they pass through the department proper quickly67. However, in a pandemic situation, waiting room overcrowding poses a significant public health risk. Patients with a potentially highly infectious illness may cross-infect other patients or visitors, as happened during the SARS outbreak in Canada in 200371.

Seasonally, influenza has been recognised to put pressure on EDs in winter through increased numbers of presentations25. Canadian studies conclude that this surge is generally associated with people over the age of 65 with pre-existing medical conditions72. In a pandemic situation, extra presentations may come from all age groups.

The role of EDs in disaster and pandemic response

Whilst vaccination is vital to stop the spread of pandemic influenza, vaccine development takes time. Community mitigation strategies such as social distancing, cough and sneeze etiquette, and frequent thorough hand washing are needed to reduce the spread of disease as much as possible in the interim25.

Stockpiling resources and equipment is a necessary part of disaster preparedness. Before the Pandemic (H1N1) 2009 Influenza, the Australian Government stockpiled antiviral agents, ventilators, and PPE. However, the distribution and dispersal of stockpiled resources during Pandemic (H1N1) 2009 Influenza became an issue73. In Canada and the USA, it was reported that stockpiled ventilators were too old or too simple to cope with the complex ventilation strategies required in severe Pandemic (H1N1) 2009 Influenza infection, with ECMO needed rather than normal ventilators74, 75.

There is contradictory information in pandemic plans devised for different sections of the health care system. For example a 2003 survey, undertaken on behalf of the Australian and New Zealand Intensive Care Society, identified hospital EDs as additional short-term bed spaces for ventilated patients in the event of a pandemic8. This ignores the issue that, during a pandemic, EDs have increased demand on their space and resources and cannot be expected to also function as satellite ICUs.

In the early weeks of Pandemic (H1N1) 2009 Influenza, the AHMPPI was criticised as suffering from too little clinician input, for having a rigid adherence to worst case scenario planning assumptions, and having a heavy focus on data management and information flow, rather than patient management. Slow distribution of PPE and antiviral medications from the national stockpile was also criticised73.

During the Toronto experience of SARS, where one patient infected many others in an ED, rigorous infection control was applied to everyone entering hospitals. In one hospital an outdoor screening area was erected, with potentially infected patients transferred directly from this area to isolation facilities. At another Toronto hospital, anyone with the potential to be infected was masked and immediately moved to a negative pressure room, regardless of their presenting complaint. Other measures employed in Toronto hospitals to prevent spread of the disease included rigorous cleaning and isolation principles, procedure and protocol lists for the use of PPE, closure of some hospital entrance points with guards at available entrances to exclude or control access to ED, exclusion of all non-essential personnel from the hospital, protocols to


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govern patient movements, alteration in ventilation to create negative pressure rooms, and the removal of all hallway stretchers. Staff updates were provided daily via bulletin boards and email. Extra housekeeping and transport staff were employed within hospitals71, 76.

During the peak of the Pandemic (H1N1) 2009 Influenza epidemic, the Texas Children’s Hospital in Houston implemented a mobile paediatric emergency response team (MPERT). The MPERT was previously used successfully in the wake of Hurricane Katrina in 2005. The MPERT was set up in a covered, open-air car park close to the ED, and all patients were triaged before entry to the hospital. Point-of-care influenza test kits were used initially, but the supply quickly ran out. Patients assessed as being probably infected with Pandemic (H1N1) 2009 Influenza were isolated, evaluated, treated, and discharged without entering the hospital unless their condition was assessed as needing emergency care or admission. Social distancing for staff was performed through infection control techniques including symptom screening, isolation, contact precautions, and the use of N95 respirators. Streamlining processes including paperwork, simultaneous nursing and medical assessment, and a designated discharge nurse educator facilitated dealing with this large influx of patients to an already stressed system. Current, multilingual advice was placed on the hospital website, and both nursing staff and automated phone lines were available to answer frequently asked questions. Printed advice was issued to parents on discharge77.

The Joe DiMaggio Children’s Hospital in Florida reported setting up an initial triage point outside the entrance to the paediatric ED, and high-risk patients were directed for further triage in the ambulance bay. Keeping patients cool, comfortable, hydrated, and fed in this environment proved to be challenging, and patient satisfaction dropped significantly during this time. However, no staff members tested positive for Pandemic (H1N1) 2009 Influenza and no cases of cross-infection were reported whilst this system was in operation. Stores of PPE and testing swabs were quickly depleted. Extra costs of more than US$3000 per day were incurred for extra staffing and equipment. Communication to the media and community was handled by administrative staff. Daily briefings were held for staff, but there was some confusion about the collection and processing of specimens despite attempts to provide a clear, consistent message78.

A trial conducted at Stanford University Hospital after the initial epidemic used volunteers acting as patients with de-identified real patient data to run a simulation trial in a covered car park near the hospital. The results indicated that off-site assessment areas may be a feasible method of rapid assessment that limits waiting times, frees space in EDs for more critically ill patients, and provides social distancing of potentially infectious patients to reduce the risk of cross-infection79.

Another method of social distancing is to triage patients over the phone. However, misdiagnoses of serious illnesses were reported in the UK where staff in call centres, with no medical training, used an algorithm to diagnose and recommend treatment for people concerned that they had Pandemic (H1N1) 2009 Influenza80–82. Wales opted out of this system for pandemic management from the beginning, as it was felt patients should be seen by clinicians83.

In disaster management, there is a risk that patients from the disaster effectively become treated as ‘Very Important Persons’ (VIPs) and receive a priority disproportionate to their clinical urgency or severity. The real risk is that seriously ill patients who are not from the ‘event’ may receive a lesser priority than those from the ‘event’ who are, in reality, less ill. Rapid development of clinical guidelines is needed to standardise the care of all patients and minimise the impact of pandemic events on other patients within the emergency health care system. The development of clinical guidelines is dependent on shared experiences and common learning from clinical exposure.


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Impact of Pandemic (H1N1) 2009 Influenza on Emergency Departments

Published figures from Australian health departments show a surge in ED presentations during the 2009 influenza season, although the timing of the increased presentations varied from state to state24. As it is already known that there are crowding problems in Australian EDs, it is logical to assume that the crowding problem was exacerbated by the Pandemic (H1N1) 2009 Influenza. Internationally, EDs reported similar experiences37. In New York City, peak increases in ED presentations occurred on the days following the first reports of Pandemic (H1N1) 2009 Influenza in New York City, and subsequently after the report of first death in New York City84. In Australia, GPs in Victoria reported coming under increased pressure from high patient numbers, inconsistent implementation of the AHMPPI, failures in the supply of PPE and antivirals from the national stockpile, time-consuming reporting requirements, delays in receiving influenza test results, delays in gaining permission to supply oseltamivir to patients, and poor communication of policy changes as the outbreak progressed85. Victoria also experienced a 30% increase in ED demand during the CONTAIN Phase of (H1N1) 2009 influenza pandemic44. A report in the Australian Nursing Journal also claims record numbers of ED presentations in Canberra during June 200984. These figures, coupled with a 16% increase in absenteeism over the previous year, caused stress within ACT Health. The higher absenteeism rate was believed to be caused by a combination of winter seasonal influences, school holidays, staff illness, and illness in families of staff. However, the report also states that two nurse-led flu clinics functioned successfully throughout the pandemic outbreak, taking a load off EDs and GPs84.

The 2003 experience of SARS in Toronto highlighted how changed operational practices necessitated by an infectious disease outbreak can add to the burden of work within the ED. Many of these changes added to an already overburdened system. The need to screen and redirect patients who present to the ED added to the triage time by requiring additional processes. Patient education for suspected cases to follow the masking and isolation protocols whilst within the ED was also time-consuming. Physical space limitations in EDs mean that patient throughput is constrained by how many patients can be seen in the available area. Alternatives to the use of nebulised medications and non-invasive assisted ventilation had to be found to prevent the potential airborne spread of disease76. Many of these challenges were replicated in the experience with the (H1N1) 2009 influenza pandemic. Extra pathology testing was required with suspected cases of Pandemic (H1N1) 2009 Influenza requiring nasopharangeal swabs. At the peak of the epidemic, laboratory testing was taking three to five days, by which time the optimal time for prescription of antivirals had passed. Whilst many EDs used rapid antigen point-of-care testing, these tests have been shown to have limited accuracy for known Pandemic (H1N1) 2009 Influenza, with rates of detection reportedly as low as 11.1%87.

Guidelines for the administration of oseltamivir recommend administration within 48 hours of onset of the disease. The time lag in getting pathology results meant oseltamivir had to be administered before pathology results were available to achieve optimal effects. Adherence to this guideline would have seen many patients treated with antiviral medication for a disease they did not have73. There is currently a great deal of debate about the efficacy of oseltamivir. The latest Cochrane Review concluded that, in healthy adults, oseltamivir only shortens the duration of symptoms by 24 hours if given within 48 hours of the onset of the disease. There is insufficient evidence of its effectiveness in preventing complications, and so it should not be given routinely for seasonal influenza88–90. There is concern that, given the general mildness of Pandemic


14

(H1N1) 2009 Influenza, oseltamivir has been overprescribed, and that an increase in resistance may occur as a result73. It is well known that it is difficult to clinically differentiate patients with influenza from those with other viral respiratory infections38. There are unnecessary risks attached to receiving treatment for a disease that the patient may not have. The side-effect profile of oseltamivir includes, most commonly, gastrointestinal symptoms and headaches but, in rare cases, delirium and psychosis (most frequently in children and adolescents), raised liver enzymes, and allergic reactions91. However, the information available at the time of the Pandemic (H1N1) 2009 Influenza outbreak, the divergence of medical opinion, and the changing nature of the advice needs to be considered in any debates about these concerns.

In the USA, it was reported that increased biosurveillance reporting requirements and increased workload during the Pandemic (H1N1) 2009 Influenza outbreak led to poor levels of reporting compliance in hospitals without automated reporting systems, compared with full compliance from hospitals with automated reporting systems85.

ED staff reported discomfort as a result of working with barrier methods of protection for frontline health care workers. Centers for Disease Control and Prevention (CDC) Guidelines assume Pandemic (H1N1) 2009 Influenza infection occurs via droplet, contact, and small aerosol transmission. Recommendations for PPE for frontline workers are based on these assumptions. PPE for health care workers in close contact with a suspected influenza patient during the (H1N1) 2009 influenza pandemic consisted of protective eyewear, an impervious gown or apron, gloves, and a fluid-repellent surgical mask. During aerosol generating procedures, P2 (N95) particulate filter masks, protective eyewear, and disposable impervious gowns and gloves were required49. PPE and other barrier methods are vital to ED staff who cannot be protected in any other way before an effective vaccine is developed. Many staff reported poor compliance with donning and removing PPE due to time constrains and discomfort, especially when the wearing of gloves, gowns, eye protection, and masks were required for prolonged periods37, 92, 93.

The CDC recommends the use of respiratory protection, at least equivalent to N95 masks13 for health care workers managing patients with ILI. However, Canadian research has found that for influenza, N95 masks are no more protective than normal surgical masks94. Users often find N95 masks uncomfortable, with somatic complaints including breathing difficulties, itching, rashes, and acne having been reported. Some users have found the masks cause difficulties with communication and establishing a therapeutic relationship with patients76, 92, 95, 96. Inconsistencies in recommendations between authorities need to be resolved to improve staff compliance37. There is consensus that particulate respirators, eye protection, and impervious gowns and gloves should be used for all aerosol-generating procedures, and that these procedures should be undertaken in a negative pressure room, if one is available38, 97, 98. Where tolerated, masking patients is probably more effective than masking health care workers99.

There have been reports of hospitals having experienced problems obtaining sufficient supplies of PPE and antivirals during the (H1N1) 2009 influenza pandemic37. In the USA, hospitals experienced storage problems for PPE and antivirals once dispensed from the national stockpile100.

Hand hygiene amongst the general public entering one New Zealand hospital after the start of the pandemic was noted to be poor, despite media campaigns, extensive signage at the hospital entrance, and obvious provision of alcohol gel. It was reported that only 18% used the alcohol gel; more people used it going into the hospital than leaving the hospital101.


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Rapidly changing guidelines created confusion for the use of PPE and other issues. Participants in a Californian workshop in September 2009 voiced frustration over rapidly changing guidelines that were not dated or timed, making it difficult to rapidly determine pertinent changes. Workshop participants also found disparities between guidance from different sources, leading to a call for a common credible source of information100.

Staffing issues

There are a number of issues that impact ED staffing during a pandemic. A key concern during the (H1N1) 2009 influenza pandemic was whether health care workers would come to work in the face of an illness of unknown severity or contagion. A survey conducted in the UK before this pandemic indicated a potential staff absenteeism rate of up to 85% during an influenza pandemic102, whilst an Australian study predicted absenteeism rates of between 17% and 53%, depending on a variety of factors. However, staff in ED and acute medical wards expressed more willingness to present for work than those working in areas in which they were less likely to be exposed103. In another UK survey, staff expressed a strong sense of duty to both patients and colleagues and intended to come to work regardless of the severity of the illness, unless their family, particularly children, needed them at home; if they were too ill to work themselves; or they had no means of getting to work if the pandemic disrupted transport104. During pandemic situations, hospital management should provide timely education and support, pre-training, evidence that staff are valued, and support for staff working outside their usual sphere of expertise105. In the UK, the nurse registering body refused to indemnify nurses who worked outside their usual field of practice during the pandemic106.

In an Australian survey of ED nurses107, most participants gave positive responses about their willingness to participate in a biological incident; however, there was a significant decrease in reported comfort levels in dealing with unknown biological agents. This survey showed that over 70% of nurses surveyed reported undertaking CBR training; however, the average time to last training was 19.2 months (SD=12)107. A survey of members of the Australasian College for Emergency Medicine in 2003 reported similar findings, with 91% of respondents stating their hospital had evaluated their major incident plan within the preceding two years. However, only 21% reported they felt their ED would cope well or very well with a biological incident, and 38% reported feeling that their ED would not cope at all108.

How far does a health care worker’s duty of care to patients go? How far does the hospital’s duty of care to its staff extend? What should be done about staff with health conditions that place them at a higher risk of infection? What is the impact on workers’ families, and their responsibilities outside the workplace? Should health care workers be forced to be immunised? Will workers comply with quarantine recommendations or take antiviral medications if exposed to the disease?

The experience of SARS gives potential insights into how health care workers may behave during a pandemic. Thirty per cent of SARS cases were health care workers, some of whom died of the infection. Whilst many workers performed with commendable dedication, there were reports of workers who refused to work with SARS patients, or who refused to work at all. Some left health care work voluntarily, and some were dismissed by their employers. Shortly after the SARS experience, professional codes of ethics came under examination, particularly in Canada, as these are useful tools for establishing both workers’ rights and responsibilities, and their ethical duties and obligations109, 110. At the time there were mixed views about the degree of duty of care that exists during outbreaks of infectious disease. Working groups could not reach consensus on the


16

degree to which health care workers owe a duty of care when their own lives, and those of their family and friends, are at risk in the course of patient care109, 110.

Whilst there has been a great deal made of an expectation of staff absenteeism during a pandemic, it is known that staff worldwide often come to work even when ill. In the tropics, influenza is under-recognised and under-diagnosed, which can lead to staff infecting their families, colleagues, and patients inadvertently111. In Scotland, a 1996 study showed that whilst 23% of staff in the study had serological evidence of influenza infection, there was only an 8% absenteeism rate in the same influenza season112. A 2007 Australian study found that 24% of medical staff and 26% of ancillary staff would present to work in spite of being symptomatic for pandemic influenza if there was a staff shortage113. This survey also found that whilst most staff would adhere to quarantine and antiviral medication directives, a large proportion would be very unhappy to do so, which could impair their adherence to these measures113. A recent Australian study reports that over one quarter of the health and community service workers surveyed would ignore a directive to remain away from work if they were diagnosed with seasonal influenza114. Fewer than half the emergency nurses in another Australian study felt adequately prepared for biological incidents; however, there was still a high degree of willingness to participate in these types of incidents: 52.9% (n = 27) willing to participate in a biological incident reported neutral or negative responses to adequacy of training107. A single hospital study in the USA undertaken after the peak of the (H1N1) 2009 influenza pandemic found that health care worker infection was highest in the adult ED, followed by the paediatric ED. It is a matter of concern that there was not a commensurate increase in sick leave in these departments, leading to the conclusion that some health care workers may have continued to work in spite of being infected with the virus115. Amongst health care workers it is known that there is a conflict between self-protection and duty of care. It has been recognised that some will work themselves to exhaustion in a crisis until ‘given permission’ to slow down105.

Recommendations from the WHO and the CDC were to redeploy staff with risk factors for severe Pandemic (H1N1) 2009 Influenza infection, which caused depletion in the ED workforce. However, not all authorities agreed with the WHO98 and CDC97 guidelines regarding staff redeployment. A joint paper published by the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), the Infectious Diseases Society of America (IDSA), and the American College of Occupational and Environmental Medicine (ACOEM) felt that this approach was neither feasible nor desirable. The paper stated redeploying staff would not only erode confidence in the efficacy of PPE and infection control guidelines, but would invade the privacy of staff who may not wish to divulge risk factors to their employers. They also cited subjectivity about risk factors such as obesity and severe asthma116. However, it would seem irresponsible for any hospital to expect people with known risk factors to expose themselves to an infection which poses greater risk to them than it does to others. Given that hospitals owe a duty of care to their employees, it would also potentially open the door to litigation should they become ill.

Staffing problems occur due to the large influx of patients, staff illness, and family obligations56. A Western Australian survey of parents whose children were in schools that were closed during the pandemic revealed that 45% of these parents took 1–5 days off to care for asymptomatic children, whilst 74% of these students participated in out-of-home activities including sporting events, shopping, outdoor recreation, and parties during the time their schools were closed. This leads to the question of how efficacious school closure is as a strategy to prevent the spread of infection117.


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Immunisation

Traditionally, hospital staff demonstrate a poor level of uptake of seasonal influenza immunisation. Rates have been reported as being between 20% and 50% across Australia118. Various reasons cited for this include a lack of perception of personal risk, poor knowledge levels of how immunisation works, doubts about vaccine efficacy or safety, self-perceived contraindications, and

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